Methadone Treatment Stakeholder Group Report

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2 Methadone Treatment Stakeholder Group Report Drafted for: Joint Standing Committee on Health and Human Services The Department of Health and Human Services Submitted: December 2015 Introduction On June 30, 2015, the Maine State Legislature passed Public Law 2015, Chapter 267, Part SS, Section 1. The law requires the Department of Health and Human Services (the Department) to assemble a stakeholder group with the purpose of assisting in reviewing and making recommendations related to methadone treatment. To develop effective reforms that incorporate appropriate viewpoints, the Department requested the attendance of a diverse array of stakeholders within the methadone treatment community including individuals in recovery, methadone treatment providers, physicians, and substance abuse experts. The law specifically tasked the Methadone Treatment Stakeholder Group (the Group) to consider appropriate criteria for treatment, consider the adequacy of existing prior authorization criteria, and assesses opportunities to improve treatment services to focus on progress, recovery, and reintegration. Following the convening of the Group, Public Law 2015, Chapter 267, Part SS, Section 2 requires the Group to submit a report to the Joint Standing Committee on Health and Human Services with its findings and any recommendations for changes. During the months of October and November, the Group convened twice at the Department of Health and Human Services, 221 State Street Augusta, Maine (see Appendix A for full attendance list). The meetings were facilitated by Dr. Christopher Pezzullo, Chief Health Officer of the Department, who led the Group through a review of Public Law 2015, Chapter 267, Part SS and discussed a list of focused questions that guided the dialogue (see Appendix B for complete question list). The Group s engagements resulted in the following recommendations and conclusions. 1 P a g e

3 Stakeholder Group- Key Themes Addressing the Underlying Issues Related to Substance Use Disorder: Throughout the stakeholder meetings, the Group made it clear that methadone treatment is evidence-based and supports individuals to manage or recover from their substance abuse disorder. However, the most effective treatment also incorporates sufficient counseling, which is not adequate for some patients at present. In addition, many individuals with a substance use disorder are furthermore faced with historical trauma and other contributing mental and behavioral health needs. As a result, the group felt that most often the genesis of addiction is trauma coupled with genetics or a pain history, and that it is imperative that methadone treatment facilities provide the correct quantity and type of behavioral health interventions to allow for the ultimate resolution of substance use disorder and recovery from methadone treatment. The Group s conversation was in line with the Federal Substance Abuse and Mental Health Services Administration (SAMHSA), which notes, Research supports the perspective that opioid addiction is a medical disorder that can be treated effectively with medications when they are administered under conditions consistent with their pharmacological efficacy and when treatment includes necessary supportive services such as psychosocial counseling, treatment for co-occurring disorders, medical services, and vocational rehabilitation. 1 It is essential that Methadone be utilized in conjunction with the appropriate behavioral health interventions to address the health of the whole person and tackle the roots of addiction. Furthermore, the Group suggested that moving from the current state regulation of dispensing 7 days per week to the federal regulation of dispensing 6 days per week, and to conform to federal regulations regarding take-home doses of methadone. Such conformity may ease barriers to treatment and may free additional clinical resources that could be utilized to supplement behavioral health care treatment in the clinic. The underlying causes of addiction must be recognized and treated appropriately, especially stressing the need for the right behavioral health services at the right time. Methadone utilization alone, without appropriate behavioral health treatment, is not adequate. 1 U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Abuse Treatment, Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Treatment Improvement Protocol (TIP) Series 43. HHS Publication No. (SMA) Rockville, MD: Substance Abuse and Mental Health Services Administration, 2005, p. xvii. 2 P a g e

4 Prior Authorization Should Focus on the Whole Person: As indicated by SAMHSA, Because some patients require assistance in many functional areas, treatment plans should address measurable, achievable goals relevant to the patient s current situation. 2 Some Group members believe that the current MaineCare Prior Authorization (PA) form at 24 months of treatment is inappropriate and may be seen as an arbitrary time period for review of accountability measures evidencing recovery. The American Society of Addiction Medicine (ASAM) criteria, used as a basis for the present 24 month P.A., is a one-size fits all methodology that does not adequately reflect evidence of progress and improvement in family, home, community, education and employment. Progress toward recovery must be clearly documented and frequently assessed. The Department will review the current PA for improvement and inclusion of more meaningful criteria. Progress toward recovery must be proactive, closely monitored, appropriate, and measurable. Recovery and reintegration, though complex, must be the ultimate goal of the Methadone Addiction Treatment (MAT) system. The Medical Profession and the Social Service System Needs to Become More Knowledgeable of and Comfortable with Substance Use Disorder Treatment: Education around the MAT system was a key theme, and the Group offered to be the genesis of an expert team that could provide both education as well as real-time assistance to Primary Care Physicians (PCPs) and the social service community. The issue of confidentiality and patient connection to medical homes or other providers is complex. The federal regulation 42 CFR, section 2 rules on confidentiality are stricter than privacy requirements of the Health Insurance Portability and Accountability Act (HIPAA), and complicate communication between an MAT and a patient s primary physician. 3 However, several MAT representatives in the Group stated that they overcome this challenge by requiring a release of information from all new patients in order to maintain communication with patient s primary care providers. One communication tool utilized by the healthcare system is the Prescription Monitoring Program (PMP) - an electronic database which contains information about all controlled substance prescriptions written in Maine. Maine has had a robust PMP for over 10 years. One concern, not adequately addressed by the Group, was the exclusion of outpatient methadone 2 U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Abuse Treatment, Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. 2005, p U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, 21 CFR Part 291, 42 CFR Part 8, Opioid Drugs in Maintenance and Detoxification Treatment of Opiate Addiction, Federal Register, Vol. 66, No. 11, 2001, p P a g e

5 treatment from the PMP. This federal requirement causes a disconnect, unfortunately isolating the methadone treatment system from the greater healthcare system. Education is needed for the medical community to better understand both the MAT system and the needs of patients in MAT. The group agreed that it could be beneficial for outpatient methadone providers to modify the current clinical structure and have primary care physicians embedded in or closely connected to these treatment facilities. The Department will review ways to educate and connect primary care providers to the MAT system. The healthcare system must be more responsive to, and educated about Substance Use Disorder. Confidentiality can be a double-edged sword, potentially isolating patients from the broader healthcare system. Opioid Prescribers Need to Recognize Their Impact on Addiction: The work group recognized that heroin addiction is often the end result of opiate prescribing and implored the health system to better understand the risks and benefits of opiate prescribing. This is consistent with ASAM s Opioid Addiction Disease 2015 Facts & Figures that concludes (nationally), About 75% of opioid addiction disease patients switch to heroin, (see Appendix D attached). Further supportive evidence for this concern can be found in the Federal CDC s Morbidity and Mortality Weekly Report on Controlled Substances and Prescribing Patterns, which states there are 855 distinct opiate prescriptions written for every 1,000 Maine state residents. 4 In addition, Maine s 2015 PMP data shows that approximately 80,000,000 opioid pills are legally distributed annually throughout the state! 5 It would follow that excessive prescriptions, resulting in the distribution of an excessive number of pills, could encourage a culture that fosters prescription drug abuse due to ease of access. MaineCare has successfully implemented policies to restrict the overprescribing of Opiates. We will continue to evaluate and improve these guidelines. The broader health care infrastructure needs to be aware of their role in the crisis of heroin addiction affecting Maine and take action toward similar policies 4 S., Rasmussen, M.D., M.S., et al., Controlled Substance Prescribing Patterns- Prescription Behavior Surveillance System, Eight States, 2013, MMWR Surveillance Summaries 2015, vol. 64, no. 9, 2015, p Flanigan, K.S., M.D., A New Approach to Pain Management: A New Utilization Pattern for Opioid Prescribing , PowerPoint, P a g e

6 Appendix A- Stakeholder Group Attendees Adolphsen, Nick: DHHS- Commissioner s Office Black, Anna: DHHS- Substance Abuse and Mental Health Services Brooks, Jamie: Individual in Recovery Cassella, Christine: Individual in Recovery Coffey, Dan: Acadia Hospital Cohen, Jim, J.D.: Verrill Dana Coutu, Katherine: DHHS- Substance Abuse and Mental Health Services D Agostino, Marietta: DHHS- Division of Licensing and Regulation Services Jorgenson, Doug, D.O.: Physician Kiezulas, Andrew: Individual in Recovery Lamensky, Tyler: DHHS- Commissioner s Office Leet, Thomas: DHHS- Office of MaineCare Services MacLean, Andy, J.D.: Maine Medical Association Martin, Kevin: Individual in Recovery Nadeau, Stefanie: DHHS- Office of MaineCare Services Norris, Merideth, D.O.: Physician Osgood, Denise: DHHS- Program Integrity Pezzullo, Chris, D.O.: DHHS- Center of Disease Control and Prevention Py, Joe, D.O.: Physician Ryder, Catherine: Tri-County Mental Health Services Senft, Samuel, J.D.: DHHS- Office of MaineCare Services Smyrski, Joan: DHHS- Substance Abuse and Mental Health Services Tompkins, Karen: Individual in Recovery 5 P a g e

7 Appendix B- Discussion Questions Treatment Criteria: Caring for the Whole Person What makes methadone a preferred treatment modality? Who is best treated with methadone and why? How do you ensure primary care participation? How do you keep MAT patients engaged in a medical home? Do you regularly communicate with the patients primary care providers? If not, what are the barriers to communication that cause the Methadone Treatment system to remain separate and non-integrated with the health care system? How do you ensure safety for the children of patients involved in MAT? Prior Approval: Evaluation and Expectation How could the ASAM criteria be used to hold providers to a measurable standard of recovery? Give examples of performance metrics utilized regarding employment rates, educational goals, family stability, etc. as they pertain to recovery from addiction. Could you give examples of a study you ve done related to this? Define and give examples of the role of CQI/QA (Continuous Quality Improvement/Quality Assurance) as it pertains to MAT (Medication Assisted Therapy). What does/should counseling look like for a typical MAT patient? Treatment Services: Opiate Addiction System Define recovery from drug addiction. What do you want us to know about addiction? What s the process of moving from methadone to another treatment or modality as a stepdown? What s the process of moving from methadone to another treatment modality if methadone treatment has not been effective? Should all patients utilizing MAT-methadone be weaned to suboxone, vivitrol or abstinence after 24 months? If not, why not? What 3 things could improve the MAT (medication assisted therapy) system in Maine? How can we better train primary care providers to assist you in addiction treatment? How would you be willing to assist in their training? 6 P a g e

8 u Appendix C- ASAM Criteria ASAM CRITERIA ASAM's criteria, formerly known as the ASAM patient placement criteria, is the result of a collaboration that began in the 1980s to define one national set of criteria for providing outcome-oriented and resultsbased care in the treatment of addiction. Today the criteria have become the most widely used and comprehensive set of guidelines for placement, continued stay and transfer/discharge of patients with addiction and co-occurring conditions. ASAM's criteria are required in over 30 states. How ASAM's Criteria Works ASAM's treatment criteria provide separate placement criteria for adolescents and adults to create comprehensive and individualized treatment plans. Adolescent and adult treatment plans are developed through a multidimensional patient assessment over five broad levels of treatment that are based on the degree of direct medical management provided, the structure, safety and security provided and the intensity of treatment services provided. 7 P a g e

9 Appendix D- ASAM Opioid Addiction Disease 2014 Facts & Figures OPIOID ADDICTION DISEASE 2015 FACTS & FIGURES Opioid Addiction Disease Basics Opioids are any of various compounds that bind to specific receptors in the central nervous system and have analgesic (pain relieving) effects including prescription medications such as oxycodone and hydrocodone and illicit substances such as heroin Opioid addiction is federally described as a progressive, treatable brain disease i ASAM Addiction Definition: Chronic, relapsing brain disease characterized by compulsive drug-seeking behavior and drug use despite harmful consequence ii Any type of opioid can trigger latent chronic addiction brain disease 24.6 million people 12 or older (9.4% of the population) live with substance dependence or abuse iii 1.9 million Americans live with prescription opioid abuse or dependence, while 517,000 Americans live with heroin addiction iv Opioid addiction disease occurs in every American State, County, socio-economic and ethnic group 23% of heroin users develop chronic opioid addiction disease National Opioid Overdose Epidemic Over 100 Americans died from overdose deaths each day in 2013 vi 46 Americans die each day from prescription opioid overdoses; two deaths an hour, 17,000 annually vii While illicit opioid heroin poisonings increased by 12.4% from 1999 to 2002, the number of prescription opioid analgesic poisonings in the United States increased by 91.2% during that same time period viii Drug overdose was the leading cause of injury death in 2013, greater than car accidents and homicide ix About 8,200 Americans die annually from heroin overdoses x About 75% of opioid addiction disease patients switch to heroin as a cheaper opioid source xi In 2012, 259 million opioid pain medication prescriptions were written, enough for every adult in America to have a bottle of pills xii Public Health Special- Populations Impact Adolescents (12 to 17 years old) Every day, 2,500 American youth abuse a prescription pain reliever for the first time xiii Nearly 1 in 20 high school seniors has taken Vicodin, 1 in 30 has abused OxyContin xiv Over 50% of individuals 12 years or older used pain relievers nonmedically from a friend or relative xv Adolescent abuse of prescription drugs is frequently associated with other risky behavior, including abuse of other drugs and alcohol xvi The number of opioids prescribed to adolescents and young adults (ages 15 to 29) nearly doubled between 1994 and 2007 xvii 8 P a g e

10 Appendix D- Continued Women Prescription opioid overdose caused five times as many women s deaths in 2010 than in 1999 xviii In 2010, more than 6,600 women died from prescription painkiller overdoses (18 each day) xix Every three minutes, a women goes to the emergency department for prescription painkiller misuse or abuse xx ASAM FACTS & FIGURES 2015: DATA SOURCES i Opioid addiction is f ederally described as a progressive, treatable brain disease, according to the American Society of Addiction Medicine s def inition of addiction. ii w w.asam.org/f or-the-public/def inition-of -addiction iii In 2013, the National Survey on Drug Use and Health (NSDUH) estimated that, w ithin the past year, 24.6 million people 12 or older (9.4 percent of the population) live w ith substance dependence or abuse, based on Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria. w w.samhsa.gov/data/sites/def ault/f iles/nsduh-s R200- Recovery Mont h- 2014/NSDUH-S R200- Recovery Mon th ht m iv In 2013, the National Survey on Drug Use and Health (NSDUH) estimated that 1.9 million Americans live w ith opioid pain reliever addiction and 517,000 are addicted to heroin. w w.samhsa.gov/data/sites/def ault/f iles/nsduh-s R2 00- RecoveryMonth- 2014/NSDUH-S R200- Recovery Mon th ht m v According to the National Institute on Drug Abuse (NIDA), about 23% of heroin users develop chronic opioid addiction disease. w w.drugabuse.gov/publications/drugf acts/heroin vi w w.cdc.gov/homeandrecreationalsaf ety/overdose/f acts.html vii According to the Centers f or Disease Control and Prevention (CDC), 46 Americans die every day f rom opioid prescription drug overdoses; that translates to almost tw o deaths an hour and 17,000 annually. CDC Vital Signs, July 2014 ( viii Paulozzi LJ. Opioid analgesic involvement in drug abuse deaths in American metropolitan areas. Am J Public Health 2006;96(10): ions.org /do i/abs/ /A JPH ?jo urnalcode =a jph ix According to statistics f rom the Centers f or Disease Control and Prevention s Web-based Injury Statistics Query and Reporting System (WISQARS) (2014), drug overdose w as the leading cause of injury death in 2012, killing more than motor vehicle accidents. x According to the Centers f or Disease Control and Prevention (CDC), more than 3,000 Americans die annually f rom heroin overdoses. w w.cdc.gov/nchs/data/databrief s/db190.htm xi ork.com/article.aspx?artic leid= xii CDC Vital Signs, July 2014 ( w w.cdc.gov/vitalsigns/opioid-prescribing/) xiii Every day, 2,500 American youth abuse a prescription pain reliever f or the f irst time, according to Foundation f or a Drug-f ree World. w w.drugf reew orld.org/drugf acts/prescription/abuse-international-statistics.html xiv Nearly 1 in 20 high school seniors have taken Vicodin and 1 in 30 has abused OxyContin, according to the National Institute on Drug Abuse, Monitoring the Future Study ( w w.drugabuse.gov/trends - statistics/monitoring-f uture/monitorin g-f uture-study- trends-in-prevalence-various-drugs) xv Substance Abuse and Mental Health Services Administration. Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2011: w w.samhsa.gov/data/sites/def ault/f iles/nsduhnat ion alfindings Results w eb/2k10resultsrev/ns DUHresults Rev20 10.p df xvi Adolescent abuse of prescription drugs f requently is associated w ith other risky behavior, according to the National Institute on Drug Abuse. xvii Fortuna RJ, Robbins BW, Caiola E, et al. Prescribing of controlled medications to adolescents and young adults in the United States. Pediatrics 2010;126(6): ent/1 26/6/ 1108.lo ng xviii Prescription opioid overdose caused f ive times as many w omen s deaths in 2010 than in 1999, according to the Centers f or Disease Control and Prevention Vital Signs Report ( w w.cdc.gov/vitalsigns/prescriptionpainkiller Overdoses/ind ex.ht ml) xix The Centers f or Disease Control and Prevention in Vital Signs, July 2013, reported that, in 2010, more than 6,600 w omen died f rom prescription painkiller overdoses (18 a day). w w.cdc.gov/vitalsigns/prescriptionpainkilleroverdoses/index.ht ml xx ographic.html 9 P a g e

11 Reference List Flanigan, K.S., M.D., A New Approach to Pain Management: A New Utilization Pattern for Opioid Prescribing , PowerPoint, Rasmussen, S., M.D., M.S., et al., Controlled Substance Prescribing Patterns- Prescription Behavior Surveillance System, Eight States, 2013, MMWR Surveillance Summaries 2015, vol. 64, no. 9, 2015, p. 5. U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Abuse Treatment, Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs, Treatment Improvement Protocol (TIP) Series 43. HHS Publication No. (SMA) Rockville, MD: Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, 21 CFR Part 291, 42 CFR Part 8, Opioid Drugs in Maintenance and Detoxification Treatment of Opiate Addiction, Federal Register, Vol. 66, No. 11, 2001, p P a g e